Inspection·March 22, 2024

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, electronic communication document review, staff interview, and non-facility staff interview, the facility failed to ensure all discharge records were completed timely so residents who were discharged could fully use their insurance benefits. This affected one resident (#81) of three resident records reviewed. The facility census was 79. Residents Affected - Few Findings Include: Review of the closed medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, low back pain, chronic viral hepatitis, paranoid schizophrenia, anxiety disorder, other recurrent depressive disorder, neuromuscular dysfunction of bladder, neurogenic bowel, muscle weakness, adult failure to thrive, chronic pain syndrome, and other psychoactive substance abuse. Review of the Minimum Data Set (MDS) assessment, dated 09/11/23, revealed Resident #81 was cognitively intact. Review of Resident #81's medical records found that he was discharged from the facility to his home on [DATE]. Review of Resident #81's 9401 State Department of Medicaid Insurance Form, dated 01/30/24, revealed the facility completed the Medicaid form to indicated he had been discharged from the facility to home/community. Review of facility email document review, dated 02/02/24, revealed Ombudsman Specialist #300 send an email to Administrator on 02/02/24, indicating they had received communication from Resident #81's insurance agent that he was still listed as being a resident of a long-term care facility. Review of facility email document review, dated 02/02/24, revealed Administrator forwarded the above email to their Corporate Business Office Staff #301. Corporate Business Office Staff #301 communicated back that Resident #81 was officially discharged from their system on 01/30/24 when the 9401 Insurance Form was completed, and it was approved for discharge by the state department of Medicaid on 02/01/24. Interview with Regional Director #302 on 03/22/24 at 12:30 P.M. revealed she received an email in February 2024 that they had not completed the 9401 form for Resident #81 at the time he was discharged . She stated she arrived at the facility in late January or early February and started to audit (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365324 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens of Belden Village 5005 Higbee Avenue NW Canton, OH 44718 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)